What is going on with my mom's liver? Her fatigue seems to be worsening.August 2, 2014 2:46 PMSubscribe

Hi all-- IANAD/YANMD/YANAD, etc., but I'm hoping I can get more insight/advice on the state of my mom's health and liver. I've been trying to make sense of a liver-related issue that has been affecting my mom (60 yr. old) for a month. Following worsening symptoms at the beginning of July (fatigue, physical exhaustion, muscle weakness and soreness, lack of appetite), she went to the ER.

At the ER, an ultrasound showed that there were no immediate liver issues. Her blood test showed high levels of AST/ASL (589/1398) and alkaline phosphatase (353). A follow-up blood test 2-3 weeks later with the family doctor indicated that AST/ASL had dropped (216/559), but the doc expressed some concern that the levels weren't as dropping as quickly as he'd have liked. No hepatitis was detected, but she has previously had Hep. A. Other data points from the follow-up: GGTP 180; alkaline phosphatase (270); low white blood count 3.8.

My mom has another follow-up blood test at the end of August, but given that she seems to be increasingly more fatigued, I'm highly concerned that there's something else going amiss. Again, all her doctor has said after her follow-up is: can't seem to figure out what's going on, try to get some rest, drink a lot of water, come back at the end of August for another follow-up. She was energetic and said she was doing great and back to her usual self. Today, she sounded very weak and flat on the phone, and has been sleeping for most of the day. In addition, she has also complained of having extreme muscle weakness/soreness in her thighs/buttock region during the past month.

Her symptoms began sometime around July 4th-- namely that she began feeling incredibly weak (not part of her usual physical well-being, as she has always been a high-energy person), unable to do much. She went to the ER, saw her family doctor soon afterward, and has been eating a light diet of fruits, juices, legumes. She has made a conscious effort to cut salt and animal fats out. It's been a month, she seemed to be doing slightly better (by better I'm going by how she sounds on the phone and what she tells me), but started to sound flat and dulled again last night.

Here's what I do know about my mom's health. She...:

* does NOT drink any alcohol, smoke, take Tylenol/Advil/the like
* discontinued generic Fosamax (alendronate) for osteoporosis after 3 months (Feb. - May of 2014)
* has known autoimmune issues such as vitiglio, psorisis on her hands
* has had Hepatitis A before
* briefly used a Chinese herbal mixture pill that claimed to reduce or eliminate vitiglio for no more than 1 week in June 2014. This Chinese herbal pill (purchased from www.merryclinic.com)was manufactured here in the US, but after some Googling, it's clear that most if not all these Chinese herbs can cause liver damage, among other things.

Her current lifestyle:She and my dad run a small business in which they do the bulk of the work themselves (not laborious, but it's not unusual for my mom to be in the office from 8am - 8pm, handling a lot of customer service calls). Taking a day off work really does not seem to be an option at this point. She is exceptional at caring for others, but pretty terrible at caring for herself. My dad is not a skilled caretaker, or a caretaker at that, so I don't expect anything to come out of asking him to look after her a bit more. I understand that we are all responsible for ourselves, but I'm an only child and caring more than normal for my mom is a vice I can't seem to shake. I have a week of weddings to attend to, so I won't be able to stay with my parents until mid-August.

My questions:
Is this normal? Is there something more sinister at play? Do any of you have recommendations, relevant personal experience you can share regarding non-type liver damage or related health issues? They will be so very much appreciated. English is not my mom's first language and I'd really like to know as much as I can to make sure nothing is slipping through the cracks. Thanks immensely.

Why has she cut animal fats and salt from her diet? Is she getting enough protein?posted by Kerasia at 3:15 PM on August 2, 2014

Does she take a statin for cholesterol control? They can cause some of the symptoms you describe and there is a rare, but very serious side effect called rhabdomyolysis that can occur.posted by quince at 3:19 PM on August 2, 2014

Is she fully hydrated? This can make a huge impact. Gatorade or a powder of electrolytes in water (Emergen-C) might be worth a try. Also, cutting out salt--why? The body needs salt to keep the water one ingests in the system, leading me back to the hydration hypothesis.posted by Riverine at 3:22 PM on August 2, 2014

She should get her vit D levels checked. Liver issues and vit D absorption are closely related and the symptoms you describe can be caused by a vit D deficiency. Her lifestyle does not sound ideal - long hours in the office and a restricted (vegan) diet are both factors that can lead to vit D deficiency. If she is deficient, there are good treatment options.posted by travelwithcats at 3:47 PM on August 2, 2014 [1 favorite]

FWIW, my mom was diagnosed with hemachromatosis sometime around that age and it (and drinking) wreaked havoc on her liver. Is this on the table?posted by plinth at 3:54 PM on August 2, 2014

If her primary physician does not have a differential of what could be causing her abnormal labs, and she's still having malaise, then it's likely time to request a referral to a hepatologist (usually grouped in the GI department). It may be also helpful to find out if she's had any weight changes - both noticeable weight gain (possibly from fluid retention) or unintentional weight loss. If her weight's been stable that's a bit more reassuring.

Some things that will also help in future visits:
*Since she's not a native English speaker, it'd be helpful for her to go with someone else who knows her can help her communicate her questions and answers (as well as remember details of the visit)
*If her providers are not in the same system, she should bring all lab and imaging reports with her to the visit (or have the ER and primary care provider fax them over...but it sounds like you have them)
*Request the physician to write down a quick summary of what the possible diagnosis is, what the next steps in management are, and what signs/symptoms should prompt a call sooner than the next visit.posted by slomodinkens at 4:03 PM on August 2, 2014 [1 favorite]

HepA isn't a chronic hepatitis, so her elevated liver enzymes probably aren't due to that part of her medical history unless she recently had HepA.

Fatigue and loss of appetite are common symptoms of liver disease, but if it's getting worse you should let your doctor know about it. Her liver enzymes were really high, and the AST/ALT ratio is over 2, plus her GGTP was elevated, which means that her liver cells were severely injured. ... if you didn't tell me that she doesn't drink at all, I'd think that she had pretty bad cirrhosis of the liver.

Has she lost weight? Does she have abdominal pain? Traveled to or lived in a country where HepE or maybe HepB -- China, Southeast Asia, Africa-- is more common? Maybe she has an acute exacerbation of a chronic hepatitis that she was not aware that she was a carrier of? Does she have type II diabetes or a family history of type II diabetes? (If you're of Asian descent... Asians have a higher risk of getting type II diabetes.) All of these are things to consider and tell your physician about.posted by gemutlichkeit at 4:14 PM on August 2, 2014 [2 favorites]

Are you sure it's liver? If she's cutting protein and with those symptoms it could chronic kidney disease. Do you know her GFR from the blood tests? This all sounds like CKD.posted by floweredfish at 4:24 PM on August 2, 2014 [1 favorite]

She needs to get a doctor who's being more aggressive about figuring out what's going on. After a month of symptoms I hope she's had more than just basic blood work and negative hepatitis panel done. She probably has and you just don't know about it, but I strongly second the suggestion for a referral to a gastroenterologist to do a further workup for her.

IANYD/This is not medical advice, but one thing that can cause a lot of nonspecific symptoms as well as weeks of fatigue and elevated liver enzymes is Epstein-Barr virus infection, otherwise known as infectious mononucleosis or "mono".posted by treehorn+bunny at 4:58 PM on August 2, 2014

Thanks for all the responses thus far. Will definitely have her get transferred to a specialist ASAP.

@quince: She's taking no meds at the moment, staying very hydrated.

@Kerasia: I should clarify-- she hasn't cut all animal fats/salt, but sticking to more white meat and seafood and eliminating red meat. Salt is still in her diet, but she is being more mindful of not oversalting/seasoning her food.

@floweredfish: In the ER, her GFR was 228.91. They told her nothing was wrong with her kidney. I know that a "normal" GFR range is above 60, but 228 seems high. Can't find more literature on it.posted by chloe.gelsomino at 9:47 PM on August 2, 2014

I know that a "normal" GFR range is above 60, but 228 seems high.

GFR just means 'glomerular filtration rate', it's an estimate of how well the kidneys are removing waste material from the blood. There isn't a 'too high' - it's not like other blood measures. However, it's not very accurate when the kidney's working OK, so there isn't likely to be a massive difference between 100 and 228, unlike say the difference between 25 and 65 which would be very significant. Absent any other evidence of kidney disease, I wouldn't worry too much about her kidneys at this point. However, the eGFR, which is probably what this is, is derived from creatinine, and a very high eGFR suggests a lowish creatinine, ~27 umol/L. This can be caused by low muscle mass, low protein intake or liver disease. Or it could just be because she's older and 'staying very hydrated'.

I'm not a doctor, I work in transplantation research.posted by Acheman at 1:59 AM on August 3, 2014

My first thought was get to a hepatologist. This is specialist territory.

A lot of people think ER is the place to go with weird stuff. ER is where you go when you have a crisis. They stabilize you and they can often identify what the area of the trouble is, but it's follow up with specialists that's important with a chronic condition.

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